Speaker 1 (00:00:00):
Hi everyone. Welcome to Hernia Talk Live. This is Dr. Shirin Towfigh. We are here on another Tuesday with our hernia type talk live session. This is Simon Cast on Facebook as well as Zoom. So thanks for everyone for joining. Today’s amazing guest is Dr. Rachel Rubin. Dr. Rubin is a board certified neurologist and an expert in sexual medicine. You can follow her on Facebook at Dr. Rachel Rubin. And I personally want to learn more about her because I’ve met her through social media, but I know of her work and I hope that you guys all learn about it as well. So please welcome Dr. Rubin. Hi.
Speaker 2 (00:00:45):
Hello. How are you? I’m
Speaker 1 (00:00:47):
Speaker 2 (00:00:48):
I just think it’s amazing. My Facebook and Instagram, Twitter friends come to life. It’s super
Speaker 1 (00:00:54):
Cool. I know, I know. I love it. So it’s a new year. You’re my first guest of the year. Congratulations. Welcome. I still have my point study as in the office leftover from this season.
Speaker 2 (00:01:06):
Happy New Year and happy holidays and it’s, thank you. It’s quite a time.
Speaker 1 (00:01:10):
Thank you. So Dr. Rubin, you’re coming in from Washington DC and you are a urologist by training and yeah, you’re most known for your expertise in sexual health, is that right?
Speaker 2 (00:01:25):
That’s correct. So whereas Urology’s a five year residency and it’s a surgical residency where you do everything. You see men, women, kidney stones, prostate cancer, bladder cancer, BPH, certainly pelvic prolapse, things like that. Many people do fellowships. And so you sub-specialized within urology. You could do a pediatric fellowship, you could do oncology. And my fellowship was actually a sexual medicine fellowship. In fact, it was actually the only fellowship in the country that even acknowledges women’s sexual health. So whereas we have lots of fellowships that deal with male sexual health, I was lucky enough to get to train actually in San Diego with my mentor, Dr. Irwin Goldstein, where we did female and male sexual medicine. So that’s my practice. I’m about five blocks from the White House and I see all genders about 50 50. Okay. And I see I deal with complex issues like complex sexual problems.
Speaker 1 (00:02:21):
And is this something that you knew going on into urology that you were going to do or how did you fall into this special?
Speaker 2 (00:02:29):
As I joke as something every girl dreamed of since she was a little girl, is that I was going to be a urologist and sex doctor. It was funny. It all fell into place. I really loved surgery, I loved complex issues, but I love, what I loved about urology was that you see all genders and you, it’s not take their appendix out and say, see you later. Right. Yeah, it it’s you get really long-term relationships with patients. Correct. And if you meet me, you know that I talk and talk and talk and that’s why my visits are so long and I am so tired at the end of the day because I haven’t stopped talking. But I love that aspect of it and I found urology, if you’re a penis doctor, you have to have a sense of humor. You can’t take yourself too seriously and you have to be personable. And so within urology, I found that I gravitated towards more complex personal issues. I was interested in people’s sexual health, I was interested in the problems, whereas I found my attendings would shy away from it a little bit. And so I found a mentor and I did my fellowship and it’s been really terrific.
Speaker 1 (00:03:29):
That’s pretty fantastic. Yeah, I always say that urologists are the funnest people at the party. You always have good stories.
Speaker 2 (00:03:36):
Female urologists, I will give a plug, are a special bunch. We all have extremely good personalities if I say so myself.
Speaker 1 (00:03:43):
Yes, that’s very, very true. And you’re not as bad as neurosurgery, but still they’re not as many female urologists as we would like.
Speaker 2 (00:03:53):
Yeah. So we’re about 8% of practicing urologists are women. Oh wow. 25% of residents and growing are female. So the future, we’re still going to be a long time before it’s equal, but we’re getting closer, but we got a long way to go.
Speaker 1 (00:04:08):
Yeah. Perfect. So we already have a lot of questions coming in. One viewer already says, I have many questions, so this is open to any questions. I primarily wanted you here because I see a lot of patients for hernias obviously, and they have either a hernia or they have a hernia related complication. Sometimes Mesh related, sometimes it’s a recurrence, sometimes they’ve injured a nerve. So many of them come in with sexual dysfunction. So either pain with orgasm, pain after intercourse, pain during intercourse, problems with erections, problems with ejaculation, or they’re totally normal, but they’re afraid if they have a hernia repair that somehow it’s going to affect their erectile function or their sexual function. So anatomically they are different. Correct. The nerves that affect orgasm or erectile are different than her groin nerves.
Speaker 2 (00:05:16):
So first of all, let me just say the fact that you, a general surgeon asks patients about their sexual function and uses words like orgasm and ejaculation. An erection is literally the greatest thing in the world. I can’t tell you how difficult it is where I ask all my female patients if they can have an orgasm. And then my next question is, has a doctor ever asked you that question? And the answer is a hundred percent no. Right? Yeah. You’ve been to a doctor, nobody ever really addresses your sexual function. And so the fact that you do as a general surge surgeon is just amazing.
Speaker 1 (00:05:47):
But well, it took me a while. I had to, you
Speaker 2 (00:05:49):
Realize, you realize it’s really important to people and as I say with sciatica right back, pain gives you sciatica. Sometimes before you get sciatica you get urinary frequency and urgency and pelvic pain, but nobody asks you about it. They just care when the sciatica happens. So I think you’re totally right. It’s understanding the nerves and what they innovate. And what I always say is my work is a detective work, so I have to figure out where is the problem. And I’m learning all the time. I’m learning from you. I’m learning from hip specialists and back specialists because you have to say, well what is this distribution? So it’s pretty interesting that men erections, orgasm and ejaculation, right? Libido four things that usually when you’re 19 and healthy, everything works together are all separate pathways. And so the nerves that supply each one are going to be different. So it depends on where the problem is.
Speaker 1 (00:06:45):
So that’s very true. In the groin, the nerves we usually talk about are the ilio inguinal nerve, the general femoral nerve and the IO hypogastric nerve. Those tend to give sensation to the skin or motor function to the cremasteric muscle, which is the muscle that moves the testicle up and down. But short of that, it doesn’t actually contribute to function.
Speaker 2 (00:07:12):
So it shouldn’t, right. So your pudendal nerve, which is the nerve that comes out under your hips, and there’s three branches both on the male side and the female side. So it innervates the penis, the perineum and the rectum or in the female side, the clitoris, the vulva and the rectum, pudendal and Latin means shame. So it’s the nerve of shame. That’s a fun fact. Interesting. That is responsible typically for your, it’s kind of the orgasm reflex, but the erections or the arousal response, well that comes more internally. It kind of comes inside, surrounds the prostate and goes through that way, kind of attacks the penis from that way. So it’s really, they’re separate nerve endings and the ones that you’re talking about. But if you have problems with sensation or that leads to pain, then that might affect your erections or your orgasm or your ability to have pleasure. And so I wouldn’t count it out completely.
Speaker 1 (00:08:06):
That’s a very good point. So it doesn’t directly affect your function, but if you have pain or pelvic floor spasm or some other hernia related problem that could indirectly, maybe it’s too painful to have an orgasm or erection because or have intercourse because of the secondary problem.
Speaker 2 (00:08:29):
Absolutely. And so it’s often that’s reversible. It’s often figuring out where is the lesion, where is the problem, is the source the nerve injury? Is the source the pelvic floor, is it from a spine issue? And thinking of it as regions, is it the penis itself or the clitoris itself? Is it the nerves innovating it? Is it the muscles that’s surrounded, is it the spine or is it the brain? Right. They all play a role.
Speaker 1 (00:08:52):
That’s true. So we already have some questions coming in. So this is relayed to male. He had a hernia repair and his one, and it was a tissue repair, no Mesh. So he had open tissue repair. Every time he has an ejaculation, his testicle pulls up into his groin. What could be the reason for that?
Speaker 2 (00:09:14):
So in that situation, I would first and foremost get you to a pelvic floor physical therapist as muscle- So the testicles start in your back when you’re in utero. And as they descend, they bring along the three layers of the abdominal wall muscles with them. And so those cremasteric muscles that you were just talking about, so the same three layers of those things that make your six pack also surround the testicle and the scrotum and so they can get tight. And so if you have a hernia repair that can affect those muscles. And sometimes a physical therapist who a pelvic floor physical therapist, they’re the greatest humans on earth, can really help work the tissue to relax it. And certainly that can be extremely successful. What have you found as successful in those situations?
Speaker 1 (00:10:00):
Yeah, so the cremasteric muscle sometimes is actually injured or the nerve to is injured or it’s actually involved in the repair. So the Shouldice clinic, for example, that does al hernia repairs, their technique they found to reduce recurrence is to actually cut the muscle. And then the result is the testicle will drag down too low and then they sew the muscle up to the pubic bone. And that’s kind of their way of handling Inguinal hernia. Most of us don’t do that, but the Shouldice clinic felt that that’s the way to reduce recurrences from the Shouldice repair. And it seems that that retraction is probably related to pelvic floor contraction and not anything related to the hernia repair necessarily. So I agree with you on that note, can you please answer this or general question, which is, what is pelvic floor dysfunction in pelvic floor spasm?
Speaker 2 (00:10:58):
Yeah, so the pelvis is just a bowl of muscle. So you’ve got your pelvis, your pelvic bone, it’s holding you up and it’s surrounded by these large layers of muscle and they do everything. Your pelvic floor allows you to relax and you can pee. It allows you to hold a fart in so that you don’t fart in the middle of a Facebook live. It allows you,
Speaker 1 (00:11:20):
I functional. Yeah,
Speaker 2 (00:11:21):
Right. It’s, it’s allowing to stretch open so you can have a baby come out of there, a bowling ball. My god, women have bowling balls that come out of there and then there’s no rehab discussed. You can have sex when you want. So the pelvic floor is responsible for so many things. And yet no, it’s muscle, right? It’s muscle. And your muscles need several things. They need to be healthy hormones, make muscles healthy, think Arnold Schwarzenegger, right? Big healthy muscles. So you need a healthy hormones, you need healthy nerves because nerves innovate muscle and you need things. Damage can, you can get damage to muscles and so they can get too tight. So I, I’d say this to all my patients, how often do you put your hand on a hot stove?
Speaker 1 (00:12:06):
Speaker 2 (00:12:07):
Never, right? Why don’t you put your hand on a hot stove,
Speaker 1 (00:12:10):
Burns you like hell, right? You’re,
Speaker 2 (00:12:12):
You’re going to completely pull away. And so if you are a person, if you’re a female who has pain with penetration or anything, a tampon and it hurts, it feels like burning hot fire, your pelvic floor muscles are going to pull away just like that hand on the fire. And so your body is there to try to protect you and to say, Hey, this isn’t right, this is not helpful. This is going to hurt. You don’t do it. And so it tightens and that’s a pelvic floor spasm. And that can occur whether you’re have a male pelvic floor or a female pelvic floor, a transgender pelvic floor and injury, different injuries, different problems can irritate the muscle, which can make them go into spasm. And if that stays along over time, it gets worse and worse and worse. The problem is so many patients are told, oh, this is all in your head, this is all anxiety, this is all in your head. Well, last time I checked anxiety was adrenaline, which contracts muscles, so anxiety and is a biological response to stress, which can tighten muscles and cause pelvic floor dysfunction.
Speaker 1 (00:13:13):
Yeah, I totally agree with that. And fun fact hernias, inguinal hernias can cause pelvic floor spasm. And what I’ve learned in my patients, I wish I could prove it, is that they have an inguinal hernia as a result of the inguinal hernia. They get pelvic floor spasm as a result of the pelvic floor spasm. They have pain with sexual intercourse, they have urinary frequency where they urinate a lot and then they’re sent, they’re, they’re seen by their gynecologist or urologist, they’re sent to pelvic floor physical therapy and it’s very painful for them to undergo pelvic four pt. You fix the hernia and the pelvic four spasm goes away and the urinary frequency goes away and the painful intercourse goes away. So we had a guest coup several weeks ago on Pudendal Neuralgia, Dr. Michael Hibner. Yeah, yeah, he’s great. And he helped explain the pelvic floor anatomy, but the pal nerve runs through the pelvic floor muscles and then if you’re, so potentially you’re can have a inguinal hernia causing pelvic floor spasm, the nerves running through those pelvic floor muscles include the pudendal nerves and now you’re contracting muscles that around this nerve. So now you have pudendal nerve type symptoms, but it’s not the pudendal nerve that’s a problem. It could be just a very simple hernia. So how do
Speaker 2 (00:14:50):
We teach more? So I don’t know how that I’m properly diagnosing. How many inguinal hernias am I missing in women? How do you examine a woman to find an inguinal hernia properly?
Speaker 1 (00:15:02):
Yeah, so when I write chapters or give talks, I try and include that information because it’s not anywhere else. But so I think the history is the most important. Hernia history is very important. So it’s usually activity related pain that’s better when you’re lying flat, worse when you’re standing or upright, coughing, bending, and then all these other things like pain with menses, pain with intercourse, et cetera. And then when you examine and you stand them up, they should be standing, not lying flat standing. And then you kind of follow the inguinal canal, which is basically a point between the anterior superior iliac spine of the hip and down to the pubic bone. Just follow that line. And within that line, if they’re tender, that’s usually highly diagnostic of an inguinal hernia as the cause of the symptoms. But they also have rating pain to the inner thigh around the lower back. There’s a lot of variation, but the history I think is much more important than that. All right. We have more.
Speaker 2 (00:16:04):
You changed. You just changed my practice. Thank you.
Speaker 1 (00:16:07):
You’re welcome. All right. So we have a gentleman who has had, sounds like a lot of complications. He’s had multiple operations that involve Mesh and in dealing with that he’s had both testicles removed, which is pretty extreme of urine and he still has a lot of pelvic pain and pain with orgasm. So he’s wondering what the next step should be like who should he be seeing for this painful orgasm? Let me just say for sure we see complications with Mesh, but to deal with the complications you should not be losing your testicle is very, very uncommon to need to lose your testicle. I know that people do have their testicle removed for either testicular pain or Mesh related pain, but you really should not need to have it done. I’ve been doing this for, it’ll be 19 years this year, I’ve taken out one testicle and that’s all I do is Mesh related complications and hernia related problems. So to lose both testicles is a bit extreme, but I’d like to know what you think about this urinary incontinence and pelvic pain. Pain after orgasm. There’s
Speaker 2 (00:17:24):
No question. There’s more to this story and that’s why these 10 minute doctor visits when you’re in and out, it’s impossible to truly understand what’s going on. And so yes, again, as we talked about earlier in the history, yes, is really understanding the history. What surgeries have you had done, what are your symptoms? And I go through a million questions in my intake to truly understand what’s going on. But first of all, if you have two testicles missing, you need hormone replacement therapy. So I very much hope that you’re on testosterone replacement and on good testosterone replacement. And that means giving you back the hormones. You don’t have checking your levels to make sure your levels are at a healthy range because in order to have healthy muscles you need healthy hormones. And so that is the first and most important thing. And then you need rehab.
Speaker 2 (00:18:13):
So if you have a knee, my mother-in-law during the middle of a global pandemic, bless her heart, had a knee replacement and Medicare paid to have a physical therapist at her house three times a week, right? This idea that you have pelvic pain, you need rehab for that pain. And so really trying to understand where is the problem and is it a specific nerve? Is it surgical related, is it your back? Is it it just the stress of everything your poor body has been through and it takes working with a team. And that’s the real struggle is building that team because we are all so busy as doctors that it’s really hard to get a team together to really focus on your issues. I wish I had a Dr. Towfigh, I wish I had a pelvic floor, everyone in one and we could all look at you and give our opinion and try to get that’s what needs to happen, but it’s impossible.
Speaker 1 (00:19:02):
Okay, so a little bit more information. This gentleman is on testosterone gel, is that enough?
Speaker 2 (00:19:09):
So it depends. So some people absorb gel gels. Great. So I love FT approved products. So gels injections, there are F FDA-approved pellets out there. And so we typically want to see the levels in the normal to upper third range, not out of the range too high, but also not in the lower range. So it it’s some people who use gels don’t absorb it so well. So it’s really important to make sure your doctor’s checking the levels while and seeing how your symptoms are.
Speaker 1 (00:19:39):
Okay. And then the other detail is that on one side he had a torsion of the testicle after a hernia repair and that’s why he lost that testicle. That’s very unfortunate. I don’t know how you can get torsion after hernia repair because that would involve a pretty abnormal testicle to begin with. And then the other side, the Mesh was wrapped about around the spermatic cord. That’s still not an indication to lose a testicle. You can tease out the Mesh off of the spermatic cord completely and still not, there’s a lot of blood vessels that come to the testicle. It’s not just through the one spermatic cord. So to lose that testicle still, I mean I guess it can happen. It’s unfortunate that it did happen, but that it in and of itself is not a reason to lose a testicle. So what I do with these patients, because we discussed before this hour, Dr.
Speaker 1 (00:20:38):
Rubin and I were talking, so in my practice, and I think in yours too, I have the luxury of sitting down with patients, giving them my full-time. And I also do what’s called, I also do what’s called online consultation. So that actually involves a lot more interaction because I can review everything and give you a complete feedback of what’s going on. But more importantly, I think the stuff that those of us that kind of do have a team, even if it’s a virtual team is I’ll look at it and be like, okay sir, so here’s what I think is going on. You live in let’s say Arizona, I know so-and-so in Arizona that you can go see, you need a urologist, you need a specialist, or it can be that you need a specific urologist like that can’t be found let’s say in Arizona. And so unfortunately it’s far further away. We’re a big country, but you may have to travel or do a zoom meeting or something to get the care that you need because when I gets to being this complicated, you really can’t rely on your local H M O that has five or 10 minutes for you. You really need much more intense care.
Speaker 2 (00:21:57):
It’s certainly a challenge and in many ways pandemic has made it really lovely. This virtual thing is actually fabulous because I can talk to someone from very far away and say, you know what? You need to go to this place. You need to go to that place and help guide and give good advice because we a subspecialist know each other, we all know each other, we all know how to find each other. And so we can help build that team. And that’s really, you know, need someone, I would say I’m the quarterback, I need to get you to the right person, the right mental health specialist, the right physical therapist, the right pelvic pain management specialist, the right spine surgeon in many cases, which is crazy. That’s true to make sure you’re getting the best care.
Speaker 1 (00:22:38):
Yeah, we were talking about patients we’ve treated as early as within the past several weeks to months. And I saw a patient who was 90 years old who was diagnosed with a hernia, underwent hernia repair and then had a second hernia, undo and redo and neurectomy and all. And he never had a hernia problem as a cause of his pain. He always had a hip problem. And we’ve talked with a hip specialist before and how the hip and the groin can kind of interact, but if you don’t listen to the patient, their symptoms, his pain was not in the groin, he was limping, he had problems walking, getting up from a sitting position that’s very hip related, but he had this bulging hernia like, okay, we’ll fix your hernia. And then he kind of went through this rabbit hole of hernia problems and then came to see me. I’m like, it’s not your hip. Don’t get all these nerves transected don’t have your third hernia surgery. And so we’re setting him up with orthopedics. The point is the history is very important and those details are super important. And then getting to the right specialists, especially when it gets to that point.
Speaker 2 (00:23:54):
So I will say the history is number one, but a very close number two, if not a one A or one B is the physical exam. And I do a lot of teaching about the vulva exam and the obviously examining penises as well. But if you go to a pelvic specialist and they’re not examining your pelvis properly, and always when I teach I say where the patient has pain is important, but where the patient doesn’t have pain is equally as important. Correct. People say it hurts down there. The problem in our society is they’re private parts, they’re private for all of us. We hide under a sheet like mechanics so that you don’t know you have to be hidden from your own body parts. And so everyone in my females in my office all get a mirror and I give them a tour of their vulvas and gynecologists are not routinely taught the vulva exam, the labia major, the labia menorah, the clitoris, the vestibule, which is honestly one of the most common causes for vulva pain. And most doctors have never heard the word vestibule before. Yes. So I get all these pain doctors who are doing pudendal nerve blocks and doing all these things, but no one’s ever examined the vulva to actually see where is the pain, where is the problem.
Speaker 1 (00:25:09):
Very, very true. We have another patient who sounds like they have complications for their Mesh implant with brain fog headache pressure, but they also have abdominal issues where they’ve lost the lower quadrant function. They feel like their abdomen is not as functional, they’re not able to contract or relax. So they’ve been referred to a pelvic floor therapist and then as well as a neurologist for additional testing and treatment. What are your thoughts on pelvic floor and abdominal wall function? Is there a correlation?
Speaker 2 (00:25:45):
Clint hurt? I never say it. It certainly can’t hurt. I’m certainly no abdominal well function expert. But it depends. Is it spasmed, is it too weak? And you need the right core strengthening exercises now that things have kind of changed in the body, that definitely could be helpful.
Speaker 1 (00:26:03):
So there are patients that have, let’s say they’re been pregnant or something, they have a very diastatic abdominal wall. So diastasis, it’s like it’s spreading apart of the abdominal muscles and they also have pelvic floor prolapse. It’s all in the same family hernias, pelvic floor, organ prolapse, recusal, cystic seal. So some people feel that if you fix their abdominal wall, do you tighten it? Then it makes their prolapse worse. Other people think no, if you’re restoring core function, your pelvic floor will also get better. Do you know anything about
Speaker 2 (00:26:42):
That? I mean, I know that pelvic floor physical therapists do a ton of diastasis correction and they can have seen incredible recoveries in terms of very large gaps, really come together with the right rehab. Again, you have to understand that role hormones play in this story that nobody puts together. When you have a new mom who when you’re pregnant, you’re okay, so here’s a good deal. If you take my blood right now, my estrogen level is probably between 50 and 150, maybe 50 and 300. If I draw my grandmother’s blood and we check for estrogen is zero, her testosterone is essentially zero. If you take a pregnant woman, her estrogen is about 3000. If I draw my husband’s blood, his estrogen is 25. Okay? So it’s really important to understand those numbers. When you’re pregnant, 3000 is your estrogen and you’ve got all these hormones and then it crashes down to zero.
Speaker 2 (00:27:38):
And if you’re breastfeeding, you are a menopausal woman, so your estrogen levels go to zero, your testosterone levels are in the tank. And so it’s really hard to build healthy muscle while you’re breastfeeding, not to say breastfeed, but understand that your body’s going to take longer to rehab itself because you don’t have the normal hormonal supplementation that keeps your muscles healthy. And so that’s why you get dryness and painful sex while you’re breastfeeding because your body doesn’t have estrogen anymore. So you can locally give estrogen, but all these women are afraid saying, oh, this is going to affect my milk supply, which it doesn’t. And so then they suffer for one year, two years, three years while they’re breastfeeding.
Speaker 1 (00:28:19):
Very interesting. It’s also why we don’t recommend any hernia pairs until three months after you’re done breastfeeding because that muscle’s very loosey-goosey.
Speaker 2 (00:28:27):
Say it again, right? As a surgeon, you don’t want to sew together wet tissue paper.
Speaker 1 (00:28:33):
Speaker 2 (00:28:33):
Right. Yeah. So you are very, very mindful of hormones without even realizing it. And that’s the problem is that’s is very selfish for most doctors where they really think about hormone status while they’re operating, but as soon as the patient walks out the door, it’s see you later. There’s no information to the patient of why it’s so important that they stay on these products like vaginal estrogen.
Speaker 1 (00:28:56):
Yeah. Okay. Another patient, again, male, six weeks after spermatic cord ablation surgery, orgasm cause extreme bloating, distension and abdominal discomfort. That has not gone away. They’re now talking about removing my left testicle. I am very anti removing of testicles. I’m sorry. There’s little indication of that.
Speaker 2 (00:29:21):
The last resort. And if you’re haven’t done physical therapy, so again, the nerves to the testicle shouldn’t be affecting your orgasm. And so it sounds like the trauma from the surgery has created a pelvic floor dysfunction. And so getting those muscles to relax, whether it’s through muscle relaxation medications, whether it’s through physical therapy or nerve blocks or things like that, it’s really important to make sure you’ve exhausted all conservative management because what’s, and even have the area blocked because if the symptoms don’t go away with a nerve block, losing your testicle is not going to help the problem. And now you’re going to have minus one testicle and continue to have the same problem.
Speaker 1 (00:30:03):
The removing a testicle never gets rid of testicular pain.
Speaker 2 (00:30:09):
So the problem is testicular pain is often referred from other places. And so that’s why I always say to my urology colleagues is these patients who we are so frustrated with the bladder pain patients, the prostatitis patients, the fall pain patients, we are frustrated because we’re not good at treating them because it’s not our organ, it’s not the testicles fault, it’s not the bladder’s fault and it’s not the prostate’s fault. It is likely the nerves and the muscles that surround them that are to blame. And so the problem is, is our spine colleagues and our hip colleagues are not really that interested. Our neurology colleagues are not really that interested. And so they come to us and expect, and we’re surgeons, so we want to cut something out, we want to do something to make it all better and we can’t do it.
Speaker 1 (00:30:54):
Yes, that’s very, very true. Let’s go ahead and review kind of why people get pain with orgasms. So this patient has pain with orgasm and she was told it’s related to her pelvic floor. How are those two related?
Speaker 2 (00:31:18):
Okay, so let’s talk for a second. I want to show one slide. Hold on.
Speaker 1 (00:31:25):
Oh, actually, here’s a cute question before I take that up. Any concerns about a male baby getting feminized if the mom is on estrogen while breastfeeding? This seems to come up often when I suggest hormones postpartum to patients.
Speaker 2 (00:31:41):
No, no, no. So remember I said my husband’s estrogen is 25. When you use vaginal estrogen, your estrogen, if you have a zero estrogen in your bloodstream, if you use vaginal estrogen, you still have zero estrogen in your bloodstream. It is a local product, so it’s not going into your bloodstream. And also it’s not going into your breast milk. It’s not causing when you would get your period back, even breastfeeding, your estrogen levels would go between 50 and 150. And so your baby’s go and your baby lived in your body when your estrogen was 3000. Right? So it’s
Speaker 1 (00:32:18):
A good point. That’s a very good point.
Speaker 2 (00:32:20):
Basically, that doesn’t really make much sense. And so we act on fear mongering when it comes to hormones. I heard hormones are dangerous, so they must be dangerous. I heard hormones are going to ruin my supply. I heard that’s going to give me breast cancer. None of those things are true, but it just keeps going and we can’t get it to go away to stop.
Speaker 1 (00:32:40):
That’s a good one. I mean, yeah, they’re being raised in a estrogen filled mom’s body. Good ques. Good answer to that one. That’s a good one. I like that Smart answer. Okay, let’s go back to that question. I have pain with orgasm. How is that related to my pelvic floor?
Speaker 2 (00:32:57):
All right, I’m going to share my screen with you. You ready?
Speaker 1 (00:32:59):
Yeah, go ahead.
Speaker 2 (00:33:03):
Tell me when you can see it. Can you see my screen?
Speaker 1 (00:33:05):
Speaker 2 (00:33:06):
All right. So I got three things on this picture, right? So whenever I see someone with any problem, the question is, and if this is a female picture of the same picture for the penis patients, you have to say what’s going on in your brain? What’s going on in your spinal cord and what’s going on with the pelvis? What is an orgasm? An orgasm is a reflex for the female. Orgasm is typically surrounded by the clitoris, although not always. There have been reports of vaginal orgasms. Cervical orgasms, interestingly enough, the cervix is triply innervated including the vagus nerve. So you can have a spinal cord injured patient who can still orgasm because of stimulation to her vagus nerve, which is fascinating. So women can orgasm from nipple stimulation from just in their sleep just thinking about it. And women can often have multiple orgasms, whereas male men often have a longer refractory period and can’t orgasm right away.
Speaker 2 (00:34:03):
And so it’s a reflex just like any other reflex. And that reflex tends to, it has to go from the source, go up the spinal cord up to the brain and then send down information. And often it comes with quite a muscle contraction that can go with it. That is often pleasurable for people. But of course there can be problems at any level here. So you can have problems in the organ itself. So the clitoris can have problems. So if you have clitoral phis or clitoral adhesions, it could be stuck. So it may be painful to the touch or it may inhibit your ability to get orgasm, whereas it’s all internal. If the penis were all internal, how would a man have an orgasm? Right? The clitoris is 90% internal. I can show you the picture of what a clitoris really looks like. It’s one of my favorite pictures in the world.
Speaker 1 (00:34:51):
I mean in gender reassignment or gender, your reassignment surgery, the clitoris becomes the penis, right? Correct.
Speaker 2 (00:35:01):
So it’s the same. So this is a clitoris. So when you think of a clitoris as just this little button right here, that’s that’s the tip of the iceberg. The clitoris is the same as a penis. There’s a big long shaft that goes all the way to the butt bones, just like the penis goes all the way to the issue, tuberosities to the button bones, and it’s made up of erectile tissue. So if you look under the microscope or you look at a cross section, the clitoral cross section’s exactly the same as the penis cross section. Wow. It’s made up of corpora cavernosum and erectile tissue. So it’s really important that this is why most women orgasm better with vibrators because most of the clitoris is internal. So you could put a vibrator here or here or here or here, but the vagina’s here, which is nowhere near the clitoris.
Speaker 2 (00:35:48):
So that’s why 82% of women do not orgasm from penetration. It’s mostly external stimulation. And even those 18% who can orgasm from penetration, and I call them my ninja unicorns, oftentimes about 36% of those require clitoral stimulation during penetration. So when I see this consult quite frequently, Dr. Rubin, I’m damaged. I can’t orgasm when my partner penetrates me. And this picture, I love showing this picture to my male patients too, because it takes a lot of pressure off their erections as the sole source of their partner’s pleasure. In fact, it often is not. It’s really this clitoris that is what provides the majority of females their sexual pleasure. And so this tissue, the nerves that, remember we talked about that pudendal nerve, the pudendal nerve innervates this tissue, and so this nerve can be damaged from sitting. Man, that Peloton bike is making me a lot of patients these days because everyone’s sitting on their $4,000 bike and they’re crushing their pudendal nerve.
Speaker 2 (00:36:55):
So they have pelvic pain, erectile dysfunction, clitoral pain. I see it all the time. And what can happen is the clitoris can become all internalized, internalized, what we call clitoral adhesions. This is what a clitoral adhesion looks like. So this is what a clitoris looks like. That’s not adhesed. So it’s the same patient. Wow, this patient, everything was internal. So she could not orgasm from hands or anything that before gave her pleasure. And afterwards, once we stretched open her clitoral hood, she was able to have a lot more pleasure. So knowing the anatomy can be very helpful to understanding where the problem is. So pain can occur in the pelvic floor. It can occur in the nerves from your spine. It can occur in lots of different places. And so you have to follow the pathway to figure out where the problem is
Speaker 1 (00:37:49):
Fascinating, but very complicated. And most people don’t know about this at all.
Speaker 2 (00:37:54):
So there is no training in general gynecology or urology on clitoral anatomy. Zero. Yeah. And so it’s really important that that training gets into medical schools. That training gets into residencies because as women, when you go for your general checkup, nobody examines your clitoris. And so how many people are saying, well, I don’t like when it’s touched. I don’t like when it’s stimulated. I guess I just can’t enjoy sex. Whereas there’s an anatomical problem, a clitoral phimosis or clitoral adhesion. And so since nobody, if we don’t ever look, how do you diagnose it? And in our research, it’s about 25% of all women, a quarter of all women have some degree of clitoral adhesions. So ladies get your mirror mirrors out.
Speaker 1 (00:38:40):
Why do they get the adhesion?
Speaker 2 (00:38:42):
So we don’t know. I have some theories myself, but there’s a lot of, we’re missing research. So I have a team of medical students right now in Chicago who are actively trying to find this answer for me. I believe I have two theories. One is hygiene. So every boy with a foreskin is taught at middle school to pull back his foreskin and clean out the smegma or oil and skin cells from underneath. And if he doesn’t do that, he will develop phimosis or penile adhesions. That’s what he’s taught. His pediatrician knows that his primary care doctor knows that and his parents know to teach him to pull back his foreskin when he is in the shower. No one on earth teaches little girls clitoral hygiene, but they have the same foreskin. So my theory is when they’re in middle school or starting to go through puberty, you should be able to pull back the hoods of their clitoris is or they should be able to. And so I think it’s a hormone issue. I think we do a lot of things to hurt testosterone levels, like birth control pills, which can dry out the tissue, which I believe probably makes for more adhesions as well. Things like these infections probably play a role. Got it. We knows sclerosis plays a role, so there’s a lot of answers there.
Speaker 1 (00:39:49):
Fascinating. Truly fascinating. I’m learning so much. I was telling, I’ll just share with the audience in general, surgery, they don’t talk anything about sexual health. We barely even know that much about gynecology or urology. We know a little bit. So we do rotate through urology. Usually not everyone does. We never rotate with gynecology. In fact, historically gynecologist were general surgeons and even urologists were general surgeons, was a general surgeon back in the day, and then they chose to kind of stay within a urologic kind of emphasis. But that’s all changed. And gynecologists don’t do any general surgery training, and we don’t do any gynecologist training. And so whatever we know is what we learn. And I’m lucky because I have a very, very narrow niche and because of what I do, I have a lot of colleagues that I work with that are outside my specialty that I learn from, and I’m kind of using hernia talk as my way of bringing another specialist.
Speaker 2 (00:40:55):
It’s brilliant. I’ve literally in my brain of how do I get more involved in is wish, which is our women’s sexual health society. That’s very multidisciplinary because it’s a big problem. It’s wonderful that we subspecialize, but again, I’m not good at diagnosing hip problems, and yet I’m in the hip. I’m working on the pelvis all the time. I’m not that good at spine pathology, but I find that most of my patients, I believe their problems are due to their spine pathology. And so we have to figure out how do we fix this in medicine, because everyone’s so busy, they’re seeing 50 patients a day. They don’t have time to learn new things. So it’s frustrating that doctors can learn how to operate with a robot, but they can’t learn how to do a vulva exam. How do we fix that
Speaker 1 (00:41:38):
Or ask the right questions
Speaker 2 (00:41:40):
Or even just ask questions at all and take more than 10 minutes.
Speaker 1 (00:41:44):
On that note, there’s someone who asks a question where they think they have a hernia or they have hernia symptoms, but they got a bunch of imaging, ct, ultrasound, MRI, all negative, which we’ve discussed this before. Doesn’t mean you don’t have, it just means the radiologist didn’t see it. So sometimes it’s a false negative. So now they’re being referred to a urogynecologist, and that’s the problem. It’s like, okay, now go to a general surgeon. They’ll say It’s not by problem. Okay, now go to a urogynecologist. They may say it’s not their problem, but there’s very little handholding and guidance for the patient. I try and do that in my practice a lot, but it’s just not feasible in most institutions to
Speaker 2 (00:42:28):
The hard part is also how do I know I got good advice? My doctor said it wasn’t a gynecology problem. How do I know that that’s true? And that can be extremely frustrating for patients. I saw a woman recently who has spent over $10,000, has traveled all over the country and had been told to use vaginal hormone therapy, but thought it was going to cause cancer and didn’t want to try it. And it turns out that that was absolutely her problem, and she just needed proper education of why that A, well, that was her problem, and B, why it was not going to cause any cancer or problems. And she’s so miserable without using it. That quality of life is really the most important thing for her, and knowing that it wouldn’t cause her harm. So it’s really frustrating to even know to be able to trust your doctors and know that they’re giving you good advice.
Speaker 1 (00:43:16):
Yeah, yeah. And it’s okay to ask for second, third, fourth opinions. Totally. Okay. Another question. Do you believe in a hormone replacement for life after menopause?
Speaker 2 (00:43:26):
Oh, I love that question. And so my answer to that is, you’re in California, right? Yeah. Have you heard, this is my example. I always give, have you heard of Caitlin Jenner?
Speaker 1 (00:43:36):
Speaker 2 (00:43:37):
Yeah. How old is Caitlin Jenner?
Speaker 1 (00:43:39):
I think 70. 70.
Speaker 2 (00:43:41):
Caitlin’s 70. When does Caitlin Jenner stop her estrogen therapy?
Speaker 1 (00:43:46):
Oh, she can’t
Speaker 2 (00:43:47):
Never. Yeah, right. You’re never going to tell Caitlin Jenner to stop her estrogen patches or pellets or whatever she’s on now. I like FDA-approved hormone therapy. And so that’s the point. I actually think we’re going to learn so much from our transgender patients about the safety of hormone therapy. And so remember I said when you’re in menopause, your estrogen is zero and a male of the same age. His estrogen is 25. So I often tell my patients, I’m just trying to get your hormone levels to that of your male partner. When I treat you in for your menopausal issues, I’m trying to keep your bones healthy, your brain healthy, keep your heart healthy. And that’s what the data overwhelmingly shows. And so we can’t talk at full length of the safety of hormone replacement therapy, but the women in that study that everyone got scared about, yes, the women who were on estrogen alone had a decreased risk of getting and dying from breast cancer. Estrogen has been protective for breast cancer. And so the things we think are true about hormone replacement therapy are actually not true, which is extremely frustrating because it It’s hard to break old myths.
Speaker 1 (00:44:56):
Yeah. Yeah, yeah, absolutely. Another similar question, does clitoral sensitivity decrease after patients have to take tamoxifen, which is an anti-estrogen for cancer?
Speaker 2 (00:45:07):
Absolutely. So no question. Tamoxifen, which is such a frustrating drug, which is why more of 50% of people go off of their tamoxifen because of what it does to the vulva. It decimate the vulva. The vulva has so many hormone receptors in it, and tamoxifen screws them all up. And so the tissue is red, it’s raw, it’s irritated. Actually, I think I have a picture of a tamoxifen vulva that’s pretty helpful to see. Wow. And no oncologists look at women’s vulvas. I had a tweet at one point of that. I wish an oncologist had to look at a vulva once a year because they would understand why their patients are stopping tamoxifen. Because it’s not just about sex. It hurts to wipe. It hurts. Here we go. This is a tamoxifen vulva. Can you see my screen here?
Speaker 1 (00:46:00):
Speaker 2 (00:46:00):
Wow. So you see how red and raw and irritated this is, right? So this is a tissues, the vestibule, this is the culprit of almost all painful sex is almost always due to this piece of tissue, which is the same as the bladder lining. So this is skin, this is endoderm here, and the vagina’s mesoderm. So it’s separate embryologic structures. And this tissue is so hormonally sensitive, whether you’re have birth control pills, breastfeeding, menopause, or breast cancer treatments, it can really hurt this tissue. So very local hormone therapy, very local, very safe, even talked about from the cancer societies and the American gynecology associations all understand that oftentimes you will need a little bit of local hormone therapy that doesn’t go into your bloodstream, that doesn’t worsen your cancer outcomes. And it can be lifesaving for women because then they can take their tamoxifen, but they can wipe and they can sit and they can have sex and they are not bothered by it. So absolutely, it can affect the clitoris, the clitoral sensitivity, and the pelvic floor. I’ve seen a lot of pelvic floor dysfunction with these types of medications.
Speaker 1 (00:47:10):
So let’s go. That was an anti-estrogen, which let’s talk about testosterone blocker. Finasteride does a man’s muscles. What does finasteride, which is a testosterone blocker do to a man’s muscles, and also the ability to heal such as after hernia surgery, does Finasteride decrease tissue muscle? So sutures are not healing while requiring a Mesh repair.
Speaker 2 (00:47:34):
I would love to do that study and oh my God, what a brilliant human you are. I
Speaker 1 (00:47:40):
Told you the questions are awful coming
Speaker 2 (00:47:43):
In. How incredible. So I see a ton of patients with sexual problems related to finasteride use. So we give Finasteride for hair loss and for big prostates. And what Finasteride does is it blocks testosterone’s conversion to DIY testosterone. And
Speaker 1 (00:47:59):
What are, just to clarify, what are the brand names of Finasteride?
Speaker 2 (00:48:02):
Yeah, so Propecia is the big one. Finasteride, I think I one. But yes, Propecia is the big one. So we call it post Finasteride syndrome. So people on Finasteride. So when you block testosterone forming to dihydro testosterone, it’s an enzyme called five alpha duct case. And this enzyme, unfortunately is responsible for a lot more than just testosterone to dihydro testosterone. This enzyme can be involved in neurosteroid synthesis. And so patients, just like I said, tamoxifen can cause all sorts of unintended consequences and birth control pills can cause unintended consequences. When you play with hormones, there are consequences, sometimes good ones and sometimes bad ones. And Finasteride is a bad player in terms of what it can do to men’s sexual function. And so we see erectile dysfunction, pelvic pain, brain fog, anxiety, depress, I mean suicide. It is a horrible medication and I believe that it really affects muscle health and that there’s a lot of muscle damage that happens after taking the medication. I would love to look at surgery repairs in men on Finasteride.
Speaker 1 (00:49:18):
Yeah, pretty interesting. But in general, we don’t change what we do and people who are taking it it,
Speaker 2 (00:49:25):
But it is just, if you could look at the muscle health or do muscle biopsies and see if there’s a change under the micro, if you can look at hormone receptors or the quality of the muscle tissue, that would be a very cool multidisciplinary sort of experiment which the NIH will not fund or pay for.
Speaker 1 (00:49:44):
Okay. I have a question about constipation, multiple questions. Can constipation make it harder to get erect in a young healthy male?
Speaker 2 (00:49:52):
Speaker 1 (00:49:54):
Speaker 2 (00:49:55):
Why not? So the nerves to your erection live that surround your prostate and your rectum is right attached to your prostate, and so if you’re full of poop you and it affects your pelvic floor, you certainly could affect those nerves. I believe it. So
Speaker 1 (00:50:11):
Interesting. Okay, cool. I thought this was going to be like a, not that interesting question, but that’s pretty cool. I didn’t even think of that.
Speaker 2 (00:50:18):
Speaker 1 (00:50:19):
Okay. What can be done for pain after bowel? I have interstitial cystitis, pelvic four disorder, hernia surgery, endometriosis, adhesions, hysterectomy, and many other operations. I used to see a gynecologist and have trigger point injections and installations probably in the bladder, but I’m having lots of pulling and pain after bowel movements, including bloating, and the pain lasts all day. I’m watching my diet and taking colase, which is a stool softener I want to take, don’t want to take vaginal volume. So I recently started an oral muscle relaxant. It has been helping, but not enough. Would Botox help? So this is pain after bowel movements.
Speaker 2 (00:51:01):
Yeah, so Botox could potentially be very helpful. Now, again, this is a situation of I’m so sorry for what you’re going through. No, this is awful. And you need a super specialist to make sure you have the right diagnosis. I mean, you need someone to be able to look at all of this and figure out where is your pain, where don’t you have pain? And really kind of work through it. Because to have a diagnosis of IC, pelvic floor dysfunction, a hernia, endometriosis, adhesions, you’re not that unlucky, right? You probably have one thing, and it is likely that if you had bad endometriosis is likely that created all the scar tissue, which affected your pelvic floor, which probably scarred your bladder, which made people give you the diagnosis of interstitial cystitis. So you have many conditions which all surround like you have. My guess is you’ve one diagnosis and that you’re seeing different providers that just call it something else. Yes. And so we have found, and it’s pretty miraculous actually, if you use botulinum toxin in the pelvic floor for the correct patient for the correct problem, it is incredible how much good it can lead to. But you have to have healthy hormones, you have to have a good pelvic floor physical therapist, you have to have the whole team together if it’s going to work. It’s a tool that we use that can be very helpful.
Speaker 1 (00:52:29):
Yeah, I hope that you’re correctly diagnosed, but I see patients who have been labeled as having interstitial cystitis, pelvic forest or endometriosis, and it was always some other issue. So it’s not uncommon to just be labeled with a diagnosis. So when people say, oh, I have interstitial cystitis, I say, okay, how was it diagnosed? Was it just someone who listened to your story said, oh, you must have interstitial cystitis. Yes. Or they actually do a urologic study with cystoscopy and install installation of the saline and looking at bleeding and all that stuff. So there’s different ways of diagnosing or endometriosis. Did they just say, oh, you have painful periods, you must have endometriosis, or did they actually treat you with some type of hormonal therapy and get you better and or do laparoscopy and see Pretty significant.
Speaker 2 (00:53:26):
What do you do when you go in for a hernia repair and you see endometriosis everywhere?
Speaker 1 (00:53:31):
Oh, well, I don’t address it myself, but that’s definitely something that hopefully they’re, they have the diagnosis before surgery. I haven’t had a situation where I had to abort hernia repair because of their endometriosis, but I operate a lot with your gynecologist who are very good at endometriosis surgery, and they either come in with me at the same time with the hernia repair and we do both. So they’ll do the endometriosis surgery and then I’ll do the hernia repair. Or they say maybe it’s, they’re actually really good also. Maybe it’s a hernia. I think it’s endo, and then we go in together and if there is a hernia, I’ll fix. If not, I’ll just basically confirm that it’s all endometriosis, but there’s so much overlap and the history and exam and everything is important. So that’s why being labeled with something, I always double triple check that the diagnosis is a real one and not just like you’ve seen a urologist, so now you have I interstitial pia, and you saw a gynecologist and now you have endometriosis and you know what I mean? Don’t
Speaker 2 (00:54:38):
Forget the GI testing you with IBS, right?
Speaker 1 (00:54:40):
Yes. Everyone has IBS. The
Speaker 2 (00:54:43):
IBS, I can’t tell you how many patients have IBS and then it’s their endometriosis causing all their bowels to be unhappy.
Speaker 1 (00:54:50):
Yeah. Yeah. Agree. Okay. Well, a lot of questions coming in, a lot of thank yous, so thank you for that. Let’s see. So based on your knowledge, but going back to the Finasteride, the Propecia Proscar discussion, do you recommend people to stop that before any operation or No,
Speaker 2 (00:55:13):
I have no data to recommend the problem. Most people on Finasteride do find, but it is a rare few that suffer the consequences, and so it’s really hard to know who’s going to have really bad problems and who isn’t, so it doesn’t go out of your system so quickly that it would probably make a difference.
Speaker 1 (00:55:32):
Okay. Got it. How do you improve clitoral tissue quality after menopause in addition to hormone replacement therapy?
Speaker 2 (00:55:40):
So really important that when you think of hormone replacement therapy, there’s systemic. So if you’re on hormone replacement for your whole body, for your hot flashes, for your night sweats, for your libido, that is for your whole body. It’s often in most of the ways that we do it, it’s often not enough for the local vulva vaginal issues, and so often using a local vaginal suppository for ring there, there’re different ways to do it, but obviously really helping with the local environment. In terms of the clitoris and clitoral adhesions, usually the local hormones are enough to keep that sensation going, to keep the size to keep the benefits. But if adhesion there and it’s severe, hormones are not going to undo the adhesion typically, and so you may need to do a lyses of that adhesion to open it up. But if it’s not causing problems or changes in your orgasm and you’re not bothered by it, it’s not something that is urgent or needs to be done.
Speaker 1 (00:56:40):
We have a complicated situation here that I’ll read to you. This is from a pelvic floor physical therapist. She has a 24 year old patient who had a sports hernia repair and then two years after the initial injury during a soccer game had lower abdominal growing pain and sudden testicular pain. He then is being seen by this physical therapist rehabilitation. The pain level improved after surgery. However, testicles are pulled high into the pubic bone. It’s very uncomfortable but not painful. He has problems with blood flow into his erection and the surgical report is very complicated, but I guess there was a labral tear for the hip, which by the way doesn’t affect testicular function as well as abdominal and pubic bone operations, which it sounds like a sports turning impaired, which does involve, depending on how they do it, it does involve tightening of the inguinal floor. So the question is, does pelvic, this patient’s pelvic floor is so tight and shortened, he has no ability to lengthen the floor. I’ve worked with him for three months, five to six hours of relief after therapy, but movement causes his testicles to pull up immediately. He is one of my trickiest patients. Can the corrections be done too tight? I feel so badly for this young guy. Sounds like a pelvic fort injury or problem. No soccer player.
Speaker 2 (00:58:16):
Yeah, I mean, he didn’t have the testicle problem, then he had surgery and now he has the testicle problem.
Speaker 2 (00:58:22):
I think that going back to his original surgeon and talking through what the actual surgery was, and that’s where the physical therapist needs to get on the phone, advocate for their patient and say, surgeon, you have to talk to me about this guy. What do we do? You are an equal team member, sort of the team, and you have to play it that way because you have to advocate for these patients. If his testicles are riding that high and being squished, yeah, I certainly would want to check hormone levels and testosterone levels, which can affect erectile function as well. So you’d want to make sure sort of that whole picture, make sure the labs are reasonable, but really, listen, the surgery sounds like it did something here, but can it undo it that is a question. I don’t know the answer to that.
Speaker 1 (00:59:05):
Yeah. Sports injuries that cause labral tears and a sports hernia can also cause injuries of the pelvic floor. So it’s possible that he has some spasm or dysfunction due to actual trauma to that I want, does Botox help with that?
Speaker 2 (00:59:24):
Yeah, it does. So I was thinking Botox could be very helpful, but it’s a big pelvic floor, so it’s knowing where to inject. Maybe the difficult part.
Speaker 1 (00:59:33):
Who does that? The Botox injection. Is that something that urologists do? Like,
Speaker 2 (00:59:38):
Oh, a specialized urologist can do Botox injections. Some of the pain management people can do it. It’s not the finding good mail. Botox injections is not so easy.
Speaker 1 (00:59:51):
Speaker 2 (00:59:52):
Some of the colorectal surgeons will do it.
Speaker 1 (00:59:55):
Yeah. In our town we have some female urology specialists do it. Not sure we have that many urogynecologists do it. And then I have this one good pain doctor who does it, but their approach is different than the urologist. But it’s it. It’s doing well. All right. That was a fast hour. Dr. Rubin, thank you so much. Thank you so much. Great information, tons of participation and questions and many that were left unanswered, but maybe we’ll have to bring you back.
Speaker 2 (01:00:30):
I got to bring you into my world and learn and have you teach us all how to rule out hernias. So thank you for teaching me and I love you on social media. I learned so much.
Speaker 1 (01:00:40):
Thank you. I love it. So please follow Dr. Rubin at Dr. Rachel Rubin on Facebook. She’s also on Instagram and Twitter. I follow her on all of those platforms. This is the end of it for hernia talk. I will make sure that you have access to this full session on my YouTube channel. I will post that on all my social media platforms. And then of course if you’re on Facebook, you can follow me at Dr. Towfigh and watch the rest of it. Come back next week. We have really amazing guests scheduled for the next several months. I’m really excited to see what they have. We have some from Europe as well as the us so going to say goodbye. Goodnight. Thank you to Dr. Rubin for using their her family time for hernia talk. I really appreciate it and goodbye and again, thank you again. Bye-bye.